Eliminating Risk of Intubation in Very Preterm Infants with Noninvasive Cardiorespiratory Support in the Delivery Room and Neonatal Intensive Care Unit

Introduction. Avoiding intubation and promoting noninvasive modes of ventilator support including continuous positive airway pressure (CPAP) in preterm infants minimizes lung injury and optimizes neonatal outcomes. Discharge home on oxygen is an expensive morbidity in very preterm infants (VPI) with lung disease. In 2007 a standardized bundle was introduced for VPI admitted to the neonatal care unit (NICU) which included delayed cord clamping (DCC) at birth and noninvasive ventilation as first-line cardiorespiratory support in the delivery room (DR), followed by bubble CPAP upon NICU admission. Objective. Our goal was to evaluate the risk of (1) intubation and (2) discharge home on oxygen after adopting this standardized DR bundle in VPI born at a regional perinatal center and treated in the NICU over a ten-year period (2008-2017). Materials and Methods. We compared maternal and neonatal demographics, respiratory care processes and outcomes, as well as neonatal mortality and morbidity in VPI (< 33 weeks gestation) and extremely low birth weight (ELBW, < 1000 g) subgroup for three consecutive epochs: 2008-2010, 2011-2013, and 2014-2017. Results. Of 640 consecutive inborn VPI, 55% were < 1500 g at birth and 23% were ELBW. Constant through all three epochs, DCC occurred in 83% of VPI at birth. There was progressive increase in maternal magnesium during the three epochs and decrease in maternal antibiotics during the last epoch. Over the three epochs, VPI had less risk of DR intubation (23% versus 15% versus 5%), NICU intubation (39% versus 31% versus 18%), and invasive ventilation (37% versus 30% versus 17%), as did ELBW infants. Decrease in postnatal steroid use, antibiotic exposure, and increase in early colostrum exposure occurred over the three epochs both in VPI and in ELBW infants. There was a sustained decrease in surfactant use in the second and third epochs. There was no significant change in mortality or any morbidity in VPI; however, there was a significant decrease in pneumothorax (17% versus 0%) and increase in survival without major morbidity (15% versus 41%) in ELBW infants between 2008-2010 and 2014-2017. Benchmarked risk-adjusted rate for oxygen at discharge in a subgroup of inborn VPI (401-1500 g or 22-31 weeks of gestation) is 2.5% (2013-2017) in our NICU compared with > 8% in all California NICUs and > 10% in all California regional NICUs (2014-2016). Conclusion. Noninvasive strategies in DR and NICU minimize risk of intubation in VPI without adversely affecting other neonatal or respiratory outcomes. Risk-adjusted rates for discharge home on oxygen remained significantly lower for inborn VPI compared with rates at regional NICUs in California. Reducing intubation risk in ELBW infants may confer an advantage for survival without major morbidity. Prenatal magnesium may reduce intubation risk in ELBW infants.

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Association of Resident Duty Hour Reform and Neonatal Outcomes of Very Preterm Infants

American Journal of Perinatology ◽

10.1055/s-0037-1603687 ◽

2017 ◽

Vol 34 (14) ◽

pp. 1396-1404

Author(s):

Bruno Piedboeuf ◽

Robert Platt ◽

Keith Barrington ◽

Victoria Bizgu ◽

Prakesh Shah ◽

...

Keyword(s):

Preterm Infants ◽

Neonatal Intensive Care ◽

Neonatal Outcomes ◽

Neonatal Intensive Care Units ◽

Composite Outcome ◽

Major Morbidity ◽

Very Preterm Infants ◽

Very Preterm ◽

Before And After ◽

Resident Duty

Objective To assess the association of the 2011 Quebec provincial resident duty hour reform, which reduced the maximum consecutive hours worked by all residents from 24 to 16 hours, with neonatal outcomes. Study Design Retrospective observational study of 4,271 infants born between 23 and 32 weeks, admitted at five Quebec neonatal intensive care units (NICUs) participating in the Canadian Neonatal Network (CNN) between 2008 and 2015 was conducted. Adjusted odds ratios (AORs) were calculated to compare mortality and the composite outcome of mortality or major morbidity before and after the implementation of the duty hour reform. Results The mortality rate was 8.4% (218/2,598) before the resident duty hour reform and 8.6% (182/2,123) after the reform (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 0.83–1.26). The composite outcome rate was 32% (830/2,598) before the duty hour reform and 29% (615/2,123) after the reform (OR = 0.87, 95% CI = 0.77–0.98). In the adjusted analyses, the resident call-hour reform was not associated with a significant change in mortality (AOR = 1.17, 95% CI = 0.91–1.50) or composite outcome (AOR = 0.87, 95% CI = 0.74–1.03). Conclusion Reducing residents' duty hours from 24 to 16 hours in Quebec was not associated with a difference in mortality or the composite outcome of very preterm infants.

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Admission hypo- and hyperthermia are associated with increased mortality and morbidity in very preterm infants

Acta Paediatrica ◽

10.1111/apa.13690 ◽

2017 ◽

Vol 106 (3) ◽

pp. 519-519

Author(s):

Julia Maletzki ◽

Stephanie Adzikah ◽

Christoph Rüegger ◽

Dirk Bassler

Keyword(s):

Preterm Infants ◽

Very Preterm Infants ◽

Mortality And Morbidity ◽

Very Preterm

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Temperature in very preterm infants from birth to neonatal intensive care unit admission

Acta Paediatrica ◽

10.1111/apa.16218 ◽

2021 ◽

Author(s):

Emma A. Dunne ◽

Colm P.F. O’Donnell ◽

Lisa K. McCarthy

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Intensive Care Unit Admission ◽

Neonatal Intensive Care Unit ◽

Preterm Infants ◽

Neonatal Intensive Care ◽

Very Preterm Infants ◽

Very Preterm

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Long-term effects of pain in infants

Oxford Textbook of Pediatric Pain ◽

10.1093/med/9780198818762.003.0004 ◽

2021 ◽

pp. 38-46

Author(s):

Ruth E. Grunau ◽

Jillian Vinall Miller ◽

Cecil M. Y. Chau

Keyword(s):

Preterm Infants ◽

Neonatal Intensive Care ◽

Pain Treatment ◽

Inflammatory Responses ◽

Imaging Techniques ◽

Preterm Neonates ◽

Long Term Effects ◽

Very Preterm Infants ◽

Very Preterm

The long-term effects of infant pain are complex, and vary depending on how early in life the exposure occurs, due to differences in developmental maturity of specific systems underway. Changes to later pain sensitivity reflect multiple factors such as age at pain stimulation, extent of tissue damage, type of noxious insult, intensity, and duration. In both full-term and preterm infants exposed to hospitalization, sequelae of early pain are confounded by parental separation and quality of pain treatment. Neonates born very preterm are outside the protective uterine environment, with repeated exposure to pain occurring during fetal life. Especially for infants born in the late second trimester, the cascade of autonomic, hormonal, and inflammatory responses to procedures may induce excitotoxicity with widespread effects on the brain. Quantitative advanced imaging techniques have revealed that neonatal pain in very preterm infants is associated with altered brain development during the neonatal period and beyond. Recent studies now provide evidence of pathways reflecting mechanisms that may underlie the emerging association between cumulative procedural pain exposure and neurodevelopment and behavior in children born very preterm. Owing to immaturity of the central nervous system, repetitive pain in very preterm neonates contributes to alterations in multiple aspects of development. Importantly, there is strong evidence that parental caregiving to reduce pain and stress in preterm infants in the Neonatal Intensive Care Unit (NICU) may prevent adverse effects, and sensitive parenting after NICU discharge may help ameliorate potential long-term effects.

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Availability of Donor Milk for Very Preterm Infants Decreased the Risk of Necrotizing Enterocolitis without Adversely Impacting Growth or Rates of Breastfeeding

Nutrients ◽

10.3390/nu11081895 ◽

2019 ◽

Vol 11 (8) ◽

pp. 1895 ◽

Cited By ~ 8

Author(s):

Débora Cañizo Vázquez ◽

Sandra Salas García ◽

Montserrat Izquierdo Renau ◽

Isabel Iglesias-Platas

Keyword(s):

Preterm Infants ◽

Necrotizing Enterocolitis ◽

Neonatal Intensive Care ◽

Late Onset ◽

Donor Milk ◽

Very Preterm Infants ◽

Very Preterm ◽

Breastfeeding Rates ◽

Group 2 ◽

Group 1

Human milk contains non-nutritional factors that promote intestinal maturation and protect against infectious and inflammatory conditions. In the Neonatal Intensive Care Unit (NICU) setting, donor milk (DM) is recommended when availability of own mother’s milk (OMM) is not enough. Our aim was to compare the incidence of necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) in very preterm infants (VPI) after the introduction of DM. Growth and breastfeeding rates were examined as secondary outcomes. Single center, observational and retrospective cohort study comparing 227 VPI admitted to our neonatal unit before (Group 1, n = 99) and after (Group 2, n = 128) DM introduction. Enteral nutrition was started earlier after DM availability (2.6 ± 1.1 vs. 2.1 ± 1 days, p = 0.001). Incidence of NEC decreased in group 2 (9.1% vs. 3.4%, p = 0.055), especially in those born between 28 and 32 weeks (5.4 vs. 0.0%, p = 0.044). Surgical NEC was also less frequent. Suffering NEC was 4 times more likely in group 1 (multivariate analysis). Availability of DM did not impact breastfeeding rates or preterm growth. Our findings support the protective role of DM against NEC, particularly in non-extreme VPI, a group less frequently included in clinical guidelines and research studies on the use of DM.

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